Provider Demographics
NPI:1629530399
Name:SULLIVAN, MICHELLE DIANNE
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:DIANNE
Last Name:SULLIVAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 UNIVERSITY CIR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:IL
Mailing Address - Zip Code:61455-1367
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1225 S GEAR AVE STE 153
Practice Address - Street 2:
Practice Address - City:W BURLINGTON
Practice Address - State:IA
Practice Address - Zip Code:52655-1686
Practice Address - Country:US
Practice Address - Phone:319-754-4400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-02
Last Update Date:2021-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.019108207Q00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine